Getting an upgrade

Ben Hoban is a GP in Exeter.

It’s a proper spring morning, the bright, exuberant kind that bounces you out of bed, no caffeine required, and she’d much rather be on the beach with the dogs, but her annual appraisal’s due and she really can’t handle another mutually respectful discussion of the pros and cons of meaningful professional development, or worse still, her appraiser’s silent disapproval. Taking a look at her consultation model feels like the least painful of her goals to try and get done, and so she takes hold of the flaking metal handrail, slowly breathes in and out to centre herself, and walks down the steps of the workshop into gloom.

A friend recommended it. She hasn’t been here before, but she can tell straightaway that it really isn’t her sort of place. The background noise is angle-grinder-with-local-radio, and she can smell some kind of specialist mechanical lubricant. The man behind the counter looks to be in his early twenties, jeans and t-shirt, something on his top lip that may once have been connected with Movember. She’s not sure if his smirk is directed at her or residual from whatever he’s been looking at on his phone. “Can I help you?” It’s only technically a question.

She looks him in the eye and lays a canvas shoulder bag on the counter in front of him. “I need an upgrade.” He undoes the leather straps and takes out an unmarked dark grey rectangular plastic case, the same one that was presented to her at the start of her training, and which still evokes the familiar mixture of excitement and regret whenever she opens it. He opens it, takes out the two halves of the device from their moulded recesses and screws them together, just as she does every day at work. He inspects it at arm’s length, noting the serial number and consultation counter, which became stuck the second time she clocked it. Without turning around, he calls over his shoulder: “Lady with a Mark IV, needs an upgrade.” The local radio keeps going in the background, but the angle grinder stops.

His colleague is middle-aged, tall, definitely overweight, slight limp, and with a stillness about him that makes her think of the estuary under a pale blue sky. He gives her the briefest of nods and gently picks up the Mark IV, holding it up to his eye and looking down its length through the viewfinder. “Nice bit of kit, had it long?” She tells him how long, almost surprising herself. “Do you see the position of the bridge? Most people have it set way too far forward when they start consulting because they can’t get to grips with the first half, and you end up with a pressure differential and a lot of wear at the other end. This is well balanced, though, which explains why you can get away with a shorter overall length; the Mark V and VI add at least an extra five minutes, and then you need a lot of fancy software to try and make up for it.” He seems pleased, and she finds herself thinking that he would make a better appraiser than her current one.

“Can you do anything with it?” she asks, feeling more at ease already. He looks up from the instrument, smiles, and lays it softly back on the counter. “Honestly? You’d be better off retiring it, it looks like it’s done everything for you that it’s going to. You might want to try a different approach, though.” He disappears under the counter for a minute and re-emerges holding something that looks vaguely familiar from medical school, like a set of obstetric forceps, but a little larger, and more asymmetrical. “All modern consultation models break down into two parts designed to help you and the patient first of all agree what the problem is and then decide what to do about it. In order to get an edge over the competition, though, the manufacturers add in so many different features, like rapport generators, ICE^* trays, alarms, and safety nets, that you end up with something that’s too big and complicated to use easily. All you really need is an opening tool and a closing tool.” As he holds up in turn the two halves of the thing that is not a pair of forceps, it is clear that he has done this before, but still enjoys it.

“You can see how the opening tool works from the curvature of the blade: you’re not grabbing anything with it, just helping something along that already wants to come out. Let the patient do the hard work, and then when they’ve told you what they need to, you can go over it quickly with the closing tool to tidy up and check for any snags. What you do then is change hands and use the opening tool to get all your medical junk on the table so that you can go over it with the patient: you can see that the closing tool has an extra handle so that you can both use it to clear away the stuff that isn’t going to be helpful and work out what to do between you.” She has already noticed the two handles, which suddenly make perfect sense: after all, the tool is not light, and why try and carry something heavy on your own?

“Not everyone gets on with them of course, and you have to be able to work together with your patient. It takes a while to get the hang of the action, and strictly speaking, they’re more old-school than next-level, but I think you could call them an upgrade.” It isn’t really a decision: she just knows that something has to change. She pays for the tools and walks out of the workshop, leaving her old model behind on the counter.

As she climbs the steps back to pavement level, she realises that she has stopped thinking about her appraisal and is looking forward to trying out the new kit. The day hasn’t lost any of its enthusiasm, and there is definitely still time for the beach.

^*Ideas, Concerns and Expectations

Featured Photo by Dom Heartley on Unsplash